Evidence-Based Medicine for Rotary Knee Instability

  • Kaitlyn L. Yin
  • Robert G. MarxEmail author


The pivot shift test is used to evaluate the knee for anterior cruciate ligament (ACL) laxity. More specifically, the pivot shift evaluates the presence of rotary knee instability, which leads to the feeling of “giving way” that patients often complain about. Evidence from the literature also shows that the pivot shift test correlates with long-term subjective patient outcomes. However, the pivot shift also has shortcomings such as a lack of a standardized maneuver and a low sensitivity without anesthesia. Due to its relevance to patients’ outcomes, we recommend using the pivot shift in conjunction with other physical examination tests, especially postoperatively, to evaluate knee stability.


Anterior Cruciate Ligament Anterior Cruciate Ligament Reconstruction Anterior Cruciate Ligament Injury Pivot Shift Knee Laxity 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


  1. 1.
    Ayeni OR, Chahal M, Tran MN, Sprague S (2012) Pivot shift as an outcome measure for ACL reconstruction: a systematic review. Knee Surg Sports Traumatol Arthrosc 20:767–777CrossRefPubMedGoogle Scholar
  2. 2.
    Donaldson WF, Warren RF, Wickiewicz T (1985) A comparison of acute anterior cruciate ligament examinations. Initial versus examination under anesthesia. Am J Sports Med 13:5–10CrossRefPubMedGoogle Scholar
  3. 3.
    Dunn WR, Schackman BR, Walsh C, Lyman S, Jones EC, Warren RF, Marx RG (2005) Variation in orthopaedic surgeons’ perceptions about the indications for rotator cuff surgery. J Bone Joint Surg Am 87:1978–1984CrossRefPubMedGoogle Scholar
  4. 4.
    Galway HR, MacIntosh DL (1980) The lateral pivot shift: a symptom and sign of anterior cruciate ligament insufficiency. Clin Orthop Relat Res 147:45–50PubMedGoogle Scholar
  5. 5.
    Hoshino Y, Araujo P, Ahlden M, Moore CG, Kuroda R, Zaffagnini S, Karlsson J, Fu FH, Musahl V (2012) Standardized pivot shift test improves measurement accuracy. Knee Surg Sports Traumatol Arthrosc 20:732–736CrossRefPubMedGoogle Scholar
  6. 6.
    Jonsson H, Riklund-Ahlström K, Lind J (2004) Positive pivot shift after ACL reconstruction predicts later osteoarthrosis: 63 patients followed 5-9 years after surgery. Acta Orthop Scand 75:594–599CrossRefPubMedGoogle Scholar
  7. 7.
    Kaplan N, Wickiewicz TL, Warren RF (1990) Primary surgical treatment of anterior cruciate ligament ruptures. A long-term follow-up study. Am J Sports Med 18:354–358CrossRefPubMedGoogle Scholar
  8. 8.
    Kim SJ, Kim HK (1995) Reliability of the anterior drawer test, the pivot shift test, and the Lachman test. Clin Orthop Relat Res 317:237–242PubMedGoogle Scholar
  9. 9.
    Kocher MS, Steadman JR, Briggs KK, Sterett WI, Hawkins RJ (2004) Relationships between objective assessment of ligament stability and subjective assessment of symptoms and function after anterior cruciate ligament reconstruction. Am J Sports Med 32:629–634CrossRefPubMedGoogle Scholar
  10. 10.
    Lane CG, Warren R, Pearle AD (2008) The pivot shift. J Am Acad Orthop Surg 16:679–688CrossRefPubMedGoogle Scholar
  11. 11.
    Lee MC, Seong SC, Lee S, Chang CB, Park YK, Jo H, Kim CH (2007) Vertical femoral tunnel placement results in rotational knee laxity after anterior cruciate ligament reconstruction. Arthroscopy 23:771–778CrossRefPubMedGoogle Scholar
  12. 12.
    Leitze Z, Losee RE, Jokl P, Johnson TR, Feagin JA (2005) Implications of the pivot shift in the ACL-deficient knee. Clin Orthop Relat Res 436:229–236CrossRefPubMedGoogle Scholar
  13. 13.
    Liu-Ambrose T (2003) The anterior cruciate ligament and functional stability of the knee joint. BCMJ 45:495–499Google Scholar
  14. 14.
    Markolf KL, Jackson SR, McAllister DR (2010) Relationship between the pivot shift and Lachman tests: a cadaver study. J Bone Joint Surg Am 92:2067–2075CrossRefPubMedGoogle Scholar
  15. 15.
    Meyer D (2004) Essential evidence-based medicine. Cambridge University Press, CambridgeGoogle Scholar
  16. 16.
    Musahl V, Hoshino Y, Ahlden M, Araujo P, Irrgang JJ, Zaffagnini S, Karlsson J, Fu FH (2012) The pivot shift: a global user guide. Knee Surg Sports Traumatol Arthrosc 20:724–731CrossRefPubMedGoogle Scholar
  17. 17.
    Scholten RJPM, Opstelten W, van der Plas CG, Bijl D, Deville WLJM, Bouter LM (2003) Accuracy of physical diagnostic tests for assessing ruptures of the anterior cruciate ligament: a meta-analysis. J Fam Pract 52:689–694PubMedGoogle Scholar
  18. 18.
    Wennberg JE (1984) Dealing with medical practice variations: a proposal for action. Health Aff (Millwood) 3(2):6–32CrossRefGoogle Scholar

Copyright information

© Springer International Publishing Switzerland 2017

Authors and Affiliations

  1. 1.Department of Orthopaedic SurgeryHospital for Special SurgeryNew YorkUSA

Personalised recommendations